After the success of previous BSNR trainee days attached to the annual meetings, this was the first of hopefully regular mid-year educational meetings, designed specifically for neuroradiology trainees to develop their knowledge coming towards consultant posts. The plan is for these to have rotating topic areas so that the breadth of neuroradiology will be covered over an approximately two-year period, corresponding to most fellowships.
The topics this year were two that trainees find notoriously tricky – paediatrics and spine – and the course took place in Newcastle at the Royal Victoria Infirmary. Below is a summary of the days to provide a flavour of the course, some learning points that I took away (would be great to hear any others from those attending!) and some key references. I apologise in advance for any butchery by paraphrasing of the excellent talks – any mistakes are mine!
The day was opened in auspicious fashion with a talk on perinatal injury by Dipayan Mitra, which covered the role of cranial ultrasound in looking for germinal matrix haemorrhage and periventricular leukomalacia, the appropriate imaging strategy for neonatal encephalopathy (the BAPM imaging guidance, available here, recommends performing MRI at 5-14 days for optimal sensitivity and accuracy), and then focused on specific imaging findings in hypoxic ischaemic injury and the imaging sequelae of early damage in cerebral palsy (see Bax et al. 2006 for a useful review). He was followed by Dr Neil Stoodley who talked about his fascinating experience as a medicolegal expert, describing his role in interesting cases and how to get into this area as a radiologist (where the demand for paediatric neuroradiologists is high!) and how to balance it with clinical work.
We have often discussed the implications of the 2016 WHO Tumour Classification in this blog, and Dan Warren provided an excellent summary relating to paediatric tumours, covering many of the new and modified tumour classifications (a useful review in Radiographics is available here, and a specific review on diffuse midline gliomas here). The emphasis is now on molecular diagnosis which is likely to override histological diagnosis (see Schindler et al. on the prevalence of a particular mutation, BRAF V600F, in multiple histological tumour types). An interesting discussion following the talk focused on our role in light of these new guidelines – how far should we go in trying to nail a molecular diagnosis, and should we avoid the old ‘histological’ diagnoses, in our imaging report? Given the difficulties, the most useful approach was felt to be a descriptive report and focused MDT discussion.
Adam Thomas broke the first rule of neurogenetics club to tell us all about this interesting innovation, which brings together all those interested and involved in the diagnosis of paediatric neurogenetic disorders for twice yearly meetings to discuss interesting and difficult cases and share experience in this complex area. He highlighted the pitfalls of pattern recognition in this context, the potential genetic underpinnings for congenital malformations, and the importance of recognising specific features in order to direct gene panels for particular imaging phenotypes, as well as MDT discussion. Most importantly was keeping an open mind (and Google browser tab)! Some of the many useful references included a review of intracranial calcifications, one of neurodegeneration with brain iron accumulation and another of cortical malformations.
The afternoon small group tutorials provided an excellent opportunity to go through these and other areas in more detail with case-based teaching on non-accidental injury, epilepsy, posterior fossa malformations, infections, white matter disorders and neurometabolic disorders. There was too much to summarise here, but the RCR/RCPCH guidance on suspected physical abuse in children (available here) is mandatory reading for those involved in paediatric neuroradiology reporting.
The day finished with current co-Du Boulay Professor Daniel Birchall giving an intriguing talk on his ‘seven effective habits of consultant radiologists’, his tips for succeeding as a consultant interspersed with personal experience. An insightful and funny approach, it was a great way to finish the day and segue into the evening social activities.
The second day began with a lively discussion around Justin Nissen’s talk on what a spinal surgeon wants from radiologists – this was a great opportunity to see from the other side, and see some of the frustrations with radiology departments as well as where we can be useful. This was followed by a great overview of vascular pathology of the spine from David Minks, going through arteriovenous fistulae and malformations as well as aneurysms and ischaemic pathologies. This led nicely into Tilak Das’s presentation on spinal cord signal change, which provided an excellent framework for assessing focal cord signal abnormality, dividing into compressive and non compressive pathologies then further into inflammatory and non-inflammatory conditions and examining useful features in each group. The diagnostic criteria for acute transverse myelitis are worth reading and suggested reviews on differential diagnosis are available here, here and here.
Spinal trauma was next on the agenda, with the other co-Du Boulay Professor Stuart Currie presenting another useful framework for approaching spinal injury, considering the role of MRI for soft tissue and spinal injury, protocolling (MRI should be performed within 72 hours of injury to pick up oedema from ligamentous injury), stability according to the Denis classification and focal cord injuries. He also highlighted the blind spot of vascular injury, crucial to consider in spinal trauma.
David Butteriss then gave a very interesting lecture on a less well-studied topic, that of imaging and treatment in intracranial hypotension, outlining the imaging features not to miss to make the diagnosis (and avoid other harmful treatment) and the role of the interventional neuroradiologist in treating, with non targeted and targeted epidural blood patching and how to hunt down the leak using the imaging available.
The afternoon consisted of five further small group tutorials, covering tumours, dysraphisms (a helpful pictorial review is available here), infection, inflammatory conditions and trauma.
Overall, it was a fantastic and very educational two days. I would like to thank all of the faculty, and particularly all of the small group tutors whose interesting cases and interactive sessions I couldn’t do justice to here, and special thanks go to the organiser Priya Bhatnagar and her team in Newcastle who put a great course together. The next one will be in Dublin in October – I hope to see you there!